Pediatric Wrist Research Articles

Surface radiation dose comparison of a dedicated extremity cone beam computed tomography (CBCT) device and a multidetector computed tomography (MDCT) machine in pediatric ankle and wrist phantoms.

ObjectivesTo evaluate and compare surface doses of a cone beam computed tomography (CBCT) and a multidetector computed tomography (MDCT) device in pediatric ankle and wrist phantoms.MethodsThermoluminescent dosimeters (TLD) were used to measure and compare surface doses between CBCT and MDCT in a left ankle and a right wrist pediatric phantom. In both modalities adapted pediatric dose protocols were utilized to achieve realistic imaging conditions. All measurements were repeated three times to prove test-retest reliability. Additionally, objective and subjective image quality parameters were assessed.ResultsAverage surface doses were 3.8 ±2.1 mGy for the ankle, and 2.2 ±1.3 mGy for the wrist in CBCT. The corresponding surface doses in optimized MDCT were 4.5 ±1.3 mGy for the ankle, and 3.4 ±0.7 mGy for the wrist. Overall, mean surface dose was significantly lower in CBCT (3.0 ±1.9 mGy vs. 3.9 ±1.2 mGy, p<0.001). Subjectively rated general image quality was not significantly different between the study protocols (p = 0.421), whereas objectively measured image quality parameters were in favor of CBCT (p<0.001).ConclusionsAdapted extremity CBCT imaging protocols have the potential to fall below optimized pediatric ankle and wrist MDCT doses at comparable image qualities. These possible dose savings warrant further development and research in pediatric extremity CBCT applications.

Ultrasonographic diagnosis of distal pediatric forearm fractures

The aim of our prospective study was to evaluate the effectivity of sonographic diagnosis of pediatric wrist fractures and analyzing the results of two pediatric musculoskeletal centers. Between 2011 January and 2015 December 467 children aged 0-15 with closed wrist injuries and open growth plates were sonographically and radiologically evaluated by an orthopaedic surgeon or a resident in trainee. Sonography was performed immediately after physical examination with linear probes of 7-14 Mhz frequency. Results were compared to conventional two plane wrist x-rays. We found 97 sensitivity and 96 specificity of the sonographic evaluation. Fractures with dislocations and more serious clinical consequences were never missed. Musculoskeletal ultrasound is a very effective tool in daily routine for diagnosing or excluding pediatric wrist fractures. Orv Hetil. 2017; 158(24): 944-948.

Minimal training sufficient to diagnose pediatric wrist fractures with ultrasound

BackgroundIn children, non-fractured wrists generally need no treatment and those that are fractured may only require a 3-week cast without any clinical follow-up. The ability to perform a point-of-care triage decision if radiographs are needed could improve patient flow and decrease unnecessary radiographs. The aim of this study was to evaluate the role of ultrasound (US) as a point-of-care triage tool for pediatric wrist injuries with limited training.MethodsPhysicians with no previous US experience attended a 1.5 h course in the use of US to diagnose distal radius fractures at the Emergency Department (ED). The physicians firstly used US to diagnose a potential fracture and, if the patient had a fracture, grouped the patient according to how they wanted him/her to be treated based on US. The physician then interpreted the subsequent radiographs and decided on a treatment based on this information. Consultant traumatologists and a senior radiologist established a gold standard for correct treatment and radiological diagnosis, respectively.ResultsOne hundred and sixteen injuries in 115 patients were included. The ED physician identified 75 fractures on radiographs. With the exception of a minimal buckle fracture, all were identified on US. US had a tendency to interpret complete fractures on radiographs as incomplete (n = 7) leading to incorrect treatment decisions.ConclusionsIn the hands of an US novice, US examination is comparable with radiographs as a point-of-care tool to distinguish a fractured wrist from a non-fractured one. US is not, however, as good as radiographs for placing fractured wrists into the correct treatment group.Level of EvidenceLevel III. Diagnostic study of non-consecutive patients.

Joint Fluid, Bone Marrow Edemalike Changes, and Ganglion Cysts in the Pediatric Wrist: Features That May Mimic Pathologic Abnormalities-Follow-Up of a Healthy Cohort.

The presence of findings at wrist MRI that may mimic disease is a diagnostic problem. The purpose of this study is to examine the occurrence of bone marrow changes resembling edema, joint fluid, and ganglion cysts over time, in a cohort of healthy children. Seventy-four of 89 healthy children included in a study of normal MRI findings of the wrists were reexamined after a period of 4 years, using the same 1.5-T MRI technique-namely, a coronal T1-weighted and a T2-weighted fat-saturated sequence. A history of handedness, diseases, and sports activity was noted. Bone marrow edema or edemalike changes were seen in 29 of 74 (39.2%) wrists in 2013 as compared with 35 of 72 (48.6%) wrists in 2009 (p = 0.153), all in different locations. Changes were found in central parts of the bone, on both sides of a joint, or near bony depressions. Fifty percent of all subjects had at least one fluid pocket greater than or equal to 2 mm. The location was unchanged in 47% of the joints. In 24% of the individuals, at least one ganglion cyst was seen. Six ganglion cysts present on the first scan were not seen on the follow-up scan, and 11 new ganglion cysts had appeared. Awareness of normal MRI appearances of the growing skeleton is crucial when interpreting MRI of children, and such findings must not be interpreted as pathologic abnormalities.

External validation of clinical decision rules for children with wrist trauma

BackgroundClinical decision rules help to avoid potentially unnecessary radiographs of the wrist, reduce waiting times and save costs.ObjectiveThe primary aim of this study was to provide an overview of all existing non-validated clinical decision rules for wrist trauma in children and to externally validate these rules in a different cohort of patients. Secondarily, we aimed to compare the performance of these rules with the validated Amsterdam Pediatric Wrist Rules.Materials and methodsWe included all studies that proposed a clinical prediction or decision rule in children presenting at the emergency department with acute wrist trauma. We performed external validation within a cohort of 379 children. We also calculated the sensitivity, specificity, negative predictive value and positive predictive value of each decision rule.ResultsWe included three clinical decision rules. The sensitivity and specificity of all clinical decision rules after external validation were between 94% and 99%, and 11% and 26%, respectively. After external validation 7% to 17% less radiographs would be ordered and 1.4% to 5.7% of all fractures would be missed. Compared to the Amsterdam Pediatric Wrist Rules only one of the three other rules had a higher sensitivity; however both the specificity and the reduction in requested radiographs were lower in the other three rules.ConclusionThe sensitivity of the three non-validated clinical decision rules is high. However the specificity and the reduction in number of requested radiographs are low. In contrast, the validated Amsterdam Pediatric Wrist Rules has an acceptable sensitivity and the greatest reduction in radiographs, at 22%, without missing any clinically relevant fractures.

Defining occult injuries of the distal forearm and wrist in children.

PurposeThe nonspecific terms “wrist sprain” and “suspected occult bony injury” are frequently documented as diagnoses in occult paediatric wrist injuries. To date, however, no one has accurately defined their true underlying pathology. The primary objective of this study was to identify the true pathoanatomy of occult acute paediatric wrist injuries. Our secondary objective was to compare our findings with existing adult data in order to determine any population differences that might be clinically relevant.MethodsWe performed a single-centre retrospective case series evaluating MRI findings in acute paediatric wrist injuries presenting to the hand injury unit between 2011 and 2014. All patients underwent standardised radiographs of the wrist and, where clinically indicated, of the scaphoid. Where no bony anomaly was identified, MRI scanning was offered. Cohen’s kappa coefficient was used to calculate the agreement between clinical and MRI diagnosis.Results57 patients met the final inclusion criteria. Occult fractures and bony contusions comprised the majority of the pathologies, at 36.5 and 35.0 %, respectively. There were no cases of isolated soft-tissue injury. MRI effected management change in 35.1 % of cases. Paediatric wrists demonstrated differences in injury pattern and distribution when compared to an adult population.ConclusionThis study defines for the first time the true pathology of occult paediatric wrist injuries. The current definition of a wrist sprain was not applicable to a single case and therefore appears to be inappropriate for use in the paediatric population. A precise knowledge of the likely pathology facilitates accurate information delivery whilst reducing parental uncertainty and treatment variation.

Wrist trauma. Diagnosis, Treatment and Prognosis

This thesis aimed to improve diagnosis, treatment and prognosis of patients with wrist trauma. To this end, we performed several multicentre prospective and retrospective studies. In Part 1, we derived and externally validated a clinical decision rule for both adult and paediatric patients with wrist trauma and named these the Amsterdam Wrist Rules (AWR) and the Amsterdam Paediatric Wrist Rules (APWR). These rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. We found that, although at the cost of missing a fracture (without therapeutic consequences) in 4.3% of the patients, the use of the APWR would have resulted in a 22% absolute reduction of radiographs. In Part 2, we performed a study to examine the variation in surgical treatment rate of patients with distal radius fractures across all Dutch hospitals and examined 95,754 reimbursements. We found that the operative rate across hospitals ranged from 0% to 23% and could not be explained by the hospital type and characteristics of the patient population. In Part 3 we focussed on the prognosis of patients with distal radius fractures. The outcome of treatment is often measured with patient-reported outcome measures such as the Patient-rated Wrist Evaluation score (PRWE). However, to interpret these results one should be aware of the minimal numeric change in score that constitutes a clinical change for the patien (the minimum clinically important difference [MCID]). We determined the MCID of the PRWE for patients with distal radius fractures and found it is 11.5 points. We recommend using this when evaluating the effects of treatments and when performing sample-size calculations for future studies.

Wrist Injuries in the Immature Athlete

The pediatric skeleton has abundant cartilage and thick periosteum shield that protect the immature athlete. Injuries can still result from excessive overuse or overt high energy trauma. This article will focus on injuries about the pediatric wrist primarily distal radius physeal stress syndrome, ulnar abutment syndrome, scaphoid fractures, and distal radius growth arrest. The diagnosis of these entities along with treatment options will be discussed. Surgical techniques to remedy these difficult problems will be highlighted. Published outcomes after the various surgical procedures will also be reviewed.

Flexor Carpi Ulnaris Myotendinous Lengthening Improves Function in Children with Spastic Hemiplegic Cerebral Palsy: Level 4 Evidence

Hypothesis: Children with spastic hemiplegic cerebral palsy with dynamic wrist flexion position during tasks, but with volitional wrist extension in isolation are often treated with Botox, which may limit muscle strength and growth. As the dynamic limitations in wrist movement are due to both abnormal myofascial loads as well as to abnormal patterns of muscle activation, we hypothesize that reducing the non-neural component via myotendinous lengthening of the flexor carpi ulnaris can reduce wrist impairment while maintaining muscle strength. Methods: We performed a respective cohort study of forty children with spastic hemiplegic cerebral palsy (mean age 10.7 years, range 4.3-to17 years old; 24 boys, 16 girls; MACS 1-4), with dynamic wrist flexion contractures who had FCU fractional lengthening as part of their single event multi-level surgery. We analyzed each child’s SHUEE (Shriners Hospital for Children Upper Extremity Evaluation) for overall scores and wrist sub-scores, wrist active range of motion, Pediatric Outcomes Data Collection Instrument (PODCI) scores, wrist flexion and extension strength, grip and pinch strength, and gross motor dexterity (box & blocks test). These measurements were obtained pre-operatively and at 1 year post-operatively. Statistical analysis was completed using data analysis tool sets, such as two-tailed ttests, in Microsoft Excel. Results: At 1 year, there were significant improvements (P 0.05) was observed in the PODCI comfort/pain subsection, SHUEE grasp and release score, wrist flexion strength, or pinch strength. Summary: In children with spastic hemiplegic cerebral palsy with volitional wrist extension and dynamic wrist flexion contractures that impair function, FCU fractional lengthening can: Improve spontaneous use Improve dynamic wrist posture Improve grip strength Improve dexterity Preserve wrist flexion strength

Epidemiologic Dynamics Contributing to Pediatric Wrist Fractures in the United States

The purpose of this study was to explore and evaluate national trends and factors contributing to pediatric wrist fractures. Over a 16-year period from January 1998 to December 2013, we identified and reviewed patients aged 0-17years old with the primary diagnosis of wrist fracture, as evaluated in US EDs and chronicled by the National Electronic Injury Surveillance System (NEISS) database of the US Consumer Product Safety Commission. We conducted descriptive epidemiologic, bivariate, and chi-square analyses. Patients were categorized into age-defined subgroups and further stratified by sex, race, location, and consumer product/activity associated with injury. There were 53,265 children evaluated in NEISS EDs (national estimate, 1,908,904) with wrist fractures from 1998 to 2013. Mean age was 10.9years, with 64% males and 36% females. The most common locations of injury were place of recreation/sports, home, and school. The top five consumer-product-related injuries were associated with bicycles, football, playground activities, basketball, and soccer. The highest subgroup associations were with beds (0-12months), stairs (13-36months), playgrounds (3-5 and 6-10years), and football (11-17years). The greatest increase in fractures occurred between ages 0-12 and 13-36months, with the second-largest increase between ages 3-5 and 6-10. It is essential to develop injury prevention and safety strategies as well as identify individual risk factors for fracture, including activity, sex, and key age transitions. Surveillance is imperative to advance our understanding of these fractures, and in the future may facilitate development of research prediction tools to anticipate or prevent injury.

Evidence into practice: emergency physician management of common pediatric fractures.

Randomized trials have shown that removable immobilization devices are at least as good as circumferential casts for the management of common specific types of pediatric wrist and ankle fractures. Our main objective was to determine the proportion of emergency physicians who prescribe removable devices for distal radius buckle fractures and/or nondisplaced distal fibular Salter-Harris I fractures. We also examined follow-up referral patterns for these injuries. This was an online survey of members of 2 national emergency physician associations in Canada: Pediatric Emergency Research Canada and the Canadian Association of Emergency Physicians. Of the 849 eligible participants, 447 responded to the survey, yielding an aggregate response rate of 52.7%. Organization-specific response rates were 169 (70.4%) of 240 for the Pediatric Emergency Research Canada and 278 (45.6%) of 609 for the Canadian Association of Emergency Physicians. Overall, 263 of 416 (63.2%; 95% confidence interval [CI], 58.6-67.8) of emergency physicians treat buckle fractures of the distal radius with a removable splint and refer 212 of 398 (53.3%; 95% CI, 48.4-58.2) of these injuries to the primary care physician for follow-up. For Salter-Harris I fractures of the distal fibula, emergency physicians treat 201 of 416 (48.3%; 95% CI, 43.5-53.1) with a removable ankle support and refer 94 of 398 (23.6%; 95% CI, 19.4-27.8) to the primary care physician for follow-up. At least 50% of the surveyed Canadian emergency physicians treat distal radius buckle fractures and/or Salter-Harris I fibular fractures with a removable immobilization device, and the primary care physician follow-up of these injuries occur with some regularity for both these injuries.

Pediatric Distal Forearm and Wrist Injury: An Imaging Review

Injuries to the pediatric distal forearm and wrist have myriad manifestations. Growth plate injuries can occur in the skeletally immature child. An unfused growth plate is less robust than ligamentous complexes and therefore is more easily injured. The Salter-Harris fracture classification system is used to grade physeal injuries based on their imaging appearance. This grading has prognostic significance: higher grades imply an increased likelihood of eventual growth disturbance. A disrupted distal radioulnar joint characterizes Galeazzi-type injuries at all ages; however, before skeletal maturity is attained, a disrupted radioulnar joint can manifest as a distal ulnar physeal separation with associated epiphysiolysis of the distal ulna, termed a Galeazzi-equivalent fracture. Bone contusions can be diagnosed using fluid-sensitive fat-suppressed magnetic resonance imaging, and their detection can alter the prognosis. The unique cartilaginous cushion of the developing bony carpus imparts resilience to fracture and dislocation until carpal maturity is reached. Chronic compressive forces to the wrist in a skeletally immature gymnast can result in a distinct pattern of bone and soft-tissue injury referred to as gymnast wrist. If the distal radial physis fuses prematurely, ulnar growth will outpace radial growth, leading to positive ulnar variance and consequent chronic wrist pain from ulnar impaction.

Pediatric wrist injury after a fall

Pediatric wrist injury after a fall

Ganglion cysts in the paediatric wrist: magnetic resonance imaging findings

The majority of published literature on ganglion cysts in children has been from a surgical perspective, with no dedicated radiologic study yet performed. Our aim was to assess the magnetic resonance (MR) imaging appearance of ganglion cysts in a series of paediatric MR wrist examinations. Ninety-seven consecutive paediatric MR wrist examinations were retrospectively reviewed for the presence of ganglion cysts. Only those studies with wrist ganglia were included. Cysts were assessed for location, size, internal characteristics and secondary effect(s). Forty-one ganglion cysts (2-32mm in size) were seen in 35/97 (36%) patients (24 female, 11 male), mean age: 13years 11months (range: 6years 3months-18years). The majority were palmar (63.4%) with the remainder dorsal. Of the cysts, 43.9% were related to a wrist ligament(s), 36.6% to a joint and 17.1% to the triangular fibrocartilage complex. Of the patients, 91.4% had wrist symptoms: pain (n=29, 82.9%), swelling (n=7, 20%) and/or palpable mass (n=4, 11.4%); 71.4% patients had significant additional wrist abnormalities. Ganglion cysts were frequently found in children referred for wrist MRI.

Pediatric hand and wrist injuries.

In the last 40years, childhood hand and wrist injuries have become progressively more common as children have become heavier and more active in high impact sports. The majority of children with such injuries do well, but treatment is not always straightforward. Distal radius fractures, scaphoid fractures, metacarpal and phalangeal fractures, nailbed injuries, and amputations are among the pediatric hand and wrist injuries most often seen by orthopedists. These are all discussed, with a focus on the most recent literature and areas of evolving controversy.

Children’s orthopaedics

The August 2012 Children’s orthopaedics Roundup360 looks at: whether 3D-CT gives a better idea of coverage than plain radiographs; forearm fractures after trampolining accidents; forearm fractures and the Rush pin; the fractured distal radius; elastic stable intramedullary nailing for long-bone fractures; aponeurotic recession for the equinus foot; the torn medial patellofemoral ligament and the adductor tubercle; slipped capital femoral epiphysis; paediatric wrist arthroscopy; and Pirani scores and clubfoot.

Pediatric hand and wrist fractures

Pediatric hand and wrist fractures

The role of plain radiography in paediatric wrist trauma

ObjectivesAcute wrist trauma in children is one of the most frequent reasons for visiting the emergency department (ED). Radiographic imaging in children with wrist trauma is mostly performed routinely to confirm or rule out a fracture. The aim of this study was to determine how many radiographs of the wrist show a fracture in children following wrist trauma.MethodsA retrospective cohort study was performed in three Dutch hospitals from 2009–2010. Data were extracted from patient records and radiographic reports.ResultsOf the 1,223 children who presented at the ED after a wrist trauma, 51 % had a wrist fracture. The peak incidence of having a wrist fracture was at the age of 10 years; 65 % of the children younger than 10 years of age had a wrist fracture. Of all the patients without a wrist fracture, 74 % were older than 10 years of age.ConclusionAlmost half of the paediatric patients with a trauma of the wrist had normal radiographs. The development of a clinical decision rule to determine when a radiograph of the wrist is indicated following acute wrist trauma is needed. This could likely reduce the number of radiographs.Main Messages Fifty-one percent of the children with wrist trauma have a wrist fracture.Peak incidence of having a wrist fracture is at the age of 10 years.Sixty-five percent of the children younger than 10 years of age had a wrist fracture.Of all the patients without a wrist fracture, 74 % were older than 10 years of age.The development of a clinical decision rule to reduce the number of radiographs is needed.

Severe infantile wrist empyema due to dental bacteremia.

Pediatric wrist empyema are very rare, this is the first case report in the current literature describing a hematogenic spreading of bacteria from dental caries, leading to a severe wrist empyema.

The paediatric wrist revisited—findings of bony depressions in healthy children on radiographs compared to MRI

The presence of erosions is used for diagnosis and monitoring of disease activity in juvenile idiopathic arthritis (JIA). Assessment of carpal bone erosions in children is challenging due to lack of normal references. To define normal appearances of bony depressions in the wrist on radiographs and MRI. MRI and radiography of the wrist were performed in 88 healthy children, 5-15 years of age. We assessed the number of bony depressions within the carpals/proximal metacarpals on both modalities, separately and combined. A total of 75 carpal depressions were identified on radiography compared to 715 on MRI. The number of bony depressions identified radiographically showed no statistically significant difference across age-groups. Within the metacarpals, there was no significant difference between bony depressions identified by MRI or radiography, except at the bases of the second metacarpal. Bony depressions that resemble erosions are normal findings in the wrist in children. MRI identifies more depressions than radiographs in the carpus. Some bony depressions occur at typical locations and should be accounted for when assessing the wrist in JIA to avoid overstaging.